Chronic Pelvic Pain - Clinicals, Diagnosis, and Management

General Gynecology

Clinicals - History

Fact Explanation
Intermittent or constant pain felt in the lower abdomen or pelvis for more than six months Increased nociceptor stimulation by the locally released inflammatory cytokines leads to perception of pain. In case of non-nociceptive chronic pain, it is considered neuropathic or psychogenic. Nerve damage following surgery,trauma, inflammation,fibrosis or infection may contribute to this pain.Persistent pain may lead to changes within the central nervous system, which may magnify the original signal. Intermittent or constant pain felt in the lower abdomen or pelvis for more than six months
Increased nociceptor stimulation by the locally released inflammatory cytokines leads to perception of pain. In case of non-nociceptive chronic pain, it is considered neuropathic or psychogenic. Nerve damage following surgery,trauma, inflammation,fibrosis or infection may contribute to this pain.Persistent pain may lead to changes within the central nervous system, which may magnify the original signal.
Pain associated with menstruation Endometriosis and/or adenomyosis can cause intermittent pelvic pain due to pelvic congestion close to menstruation. Pain associated with menstruation
Endometriosis and/or adenomyosis can cause intermittent pelvic pain due to pelvic congestion close to menstruation.
Deep dysperunia Presence of pelvic adhesions or pelvic infections can cause pelvic pain during sexual intercourse Deep dysperunia
Presence of pelvic adhesions or pelvic infections can cause pelvic pain during sexual intercourse
Pain associated with defaecation Irritable bowel syndrome can cause chronic intermittent pelvic pain associated with bowel motion. Pain associated with defaecation
Irritable bowel syndrome can cause chronic intermittent pelvic pain associated with bowel motion.
Pain associated with urination Due to painful bladder syndrome or interstitial cystitis bladder becomes sensitive and easily irritated causing chronic pelvic pain associated with urination. Pain associated with urination
Due to painful bladder syndrome or interstitial cystitis bladder becomes sensitive and easily irritated causing chronic pelvic pain associated with urination.
Post-coital bleedind Pelvic pain associated with post coital bleeding can occur in patients who have cervical cancer. Post-coital bleedind
Pelvic pain associated with post coital bleeding can occur in patients who have cervical cancer.
Perimenopausal irregular bleeding This symptom associated with pelvic pain may be a feature of endometrial cancer Perimenopausal irregular bleeding
This symptom associated with pelvic pain may be a feature of endometrial cancer
Postmenopausal vaginal bleeding This symptom also may be associated with endometrial cancer. Postmenopausal vaginal bleeding
This symptom also may be associated with endometrial cancer.
Unexplained weight loss This symptom together with chronic pelvic pain may be the first presentation of a gynecological malignancy. Unexplained weight loss
This symptom together with chronic pelvic pain may be the first presentation of a gynecological malignancy.
History of physical or sexual abuse Some patients with a history of physical or sexual abuse may experience psychogenic chronic pelvic pain. History of physical or sexual abuse
Some patients with a history of physical or sexual abuse may experience psychogenic chronic pelvic pain.
History of pelvic surgery Pelvic surgery may leave behind scar tissue and adhesions with other organs which may cause pain particularly on organ distension or stretching.Dense vascular adhesions may cause chronic pelvic pain. History of pelvic surgery
Pelvic surgery may leave behind scar tissue and adhesions with other organs which may cause pain particularly on organ distension or stretching.Dense vascular adhesions may cause chronic pelvic pain.
History of pelvic infections or sexually transmitted infections Chronic changes following pelvic inflammatory disease occur in about one-third of women and can cause chronic pelvic pain. The reason for this is not clearly known, but is probably because of permanent damage to the uterus, ovaries, and fallopian tubes. History of pelvic infections or sexually transmitted infections
Chronic changes following pelvic inflammatory disease occur in about one-third of women and can cause chronic pelvic pain. The reason for this is not clearly known, but is probably because of permanent damage to the uterus, ovaries, and fallopian tubes.
Use of an intrauterine device Presence of an intrauterine device produce localized endometrial ulceration, inflammation and endometrial prostaglandin release which stimulates local pain sensitive nerve endings leading to pelvic pain Use of an intrauterine device
Presence of an intrauterine device produce localized endometrial ulceration, inflammation and endometrial prostaglandin release which stimulates local pain sensitive nerve endings leading to pelvic pain
History of pelvic irradiation Adhesions (abnormal tissue that causes internal organs or structures, such as the ovaries and fallopian tubes, to adhere to one another) which can occur following pelvic irradiation can cause chronic pelvic pain. History of pelvic irradiation
Adhesions (abnormal tissue that causes internal organs or structures, such as the ovaries and fallopian tubes, to adhere to one another) which can occur following pelvic irradiation can cause chronic pelvic pain.

Clinicals - Examination

Fact Explanation
Lack of uterus mobility on bimanual examination Due to presence of endometriosis or pelvic adhesions. Lack of uterus mobility on bimanual examination
Due to presence of endometriosis or pelvic adhesions.
Nodularity or masses on abdominal, bimanual pelvic and/or rectal examination Presence of adenomyosis, endometriosis, malignancy, tumors can give rise to this sign. Nodularity or masses on abdominal, bimanual pelvic and/or rectal examination
Presence of adenomyosis, endometriosis, malignancy, tumors can give rise to this sign.
Pain on palpation of outer back and outer pelvis Due to presence of abdominal/pelvic wall source of pain, trigger points. Pain on palpation of outer back and outer pelvis
Due to presence of abdominal/pelvic wall source of pain, trigger points.
Point tenderness of vagina, vulva, or bladder Adhesions, endometriosis, nerve entrapment, trigger points, vulvar vestibulitis can cause this sign. Point tenderness of vagina, vulva, or bladder
Adhesions, endometriosis, nerve entrapment, trigger points, vulvar vestibulitis can cause this sign.
Tenderness in sacroiliac joints or the symphysis pubis Occurs when the pain is musculoskeletal in origin. Tenderness in sacroiliac joints or the symphysis pubis
Occurs when the pain is musculoskeletal in origin.

Investigations - Diagnosis

Fact Explanation
Diagnostic laparoscopy This is the test capable of reliably diagnosing peritoneal endometriosis and adhesion. It can also detect any pelvic masses Diagnostic laparoscopy
This is the test capable of reliably diagnosing peritoneal endometriosis and adhesion. It can also detect any pelvic masses
Transvaginal scanning (TVS) Done to identify and assess adnexal masses. Also a useful test to diagnose adenomyosis. Transvaginal scanning (TVS)
Done to identify and assess adnexal masses. Also a useful test to diagnose adenomyosis.
Magnetic resonance imaging (MRI) A useful test to diagnose adenomyosis. Magnetic resonance imaging (MRI)
A useful test to diagnose adenomyosis.
Gonorrhea/chlamydia testing/ Screening for sexually transmitted infections Done if there is any suspicion of pelvic inflammatory disease Gonorrhea/chlamydia testing/ Screening for sexually transmitted infections
Done if there is any suspicion of pelvic inflammatory disease
Urine full report and urine culture Done if there is suspicion of bladder malignancy and urinary tract infection Urine full report and urine culture
Done if there is suspicion of bladder malignancy and urinary tract infection

Investigations - Management

Fact Explanation
Complete blood count analysis Can indicate presence of Infection, systemic illness, or malignancy Complete blood count analysis
Can indicate presence of Infection, systemic illness, or malignancy
CA125 Done if ovarian cancer is suspected. Particularly in women over the age of 50 years CA125
Done if ovarian cancer is suspected. Particularly in women over the age of 50 years

Management - Supportive

Fact Explanation
Maintain good posture Reduces chronic pelvic pain of musculoskeletal origin. Maintain good posture
Reduces chronic pelvic pain of musculoskeletal origin.
Pelvic floor excercise Helps in patients with pelvic floor dysfunction. Pelvic floor excercise
Helps in patients with pelvic floor dysfunction.
Nutrition therapy Vitamin B1 and magnesium has shown to reduce dysmenorrhoea. Nutrition therapy
Vitamin B1 and magnesium has shown to reduce dysmenorrhoea.
Psychological councelling Cognitive behavioral therapy has been found to be helpful in many people with chronic pain.Relaxation techniques can relieve musculoskeletal tension. Psychological councelling
Cognitive behavioral therapy has been found to be helpful in many people with chronic pain.Relaxation techniques can relieve musculoskeletal tension.

Management - Specific

Fact Explanation
Medical therapy Should offer appropriate analgesia to control the pain.Women with cyclical pain should be offered a therapeutic trial using hormonal treatment for a period of
3–6 months before having a diagnostic laparoscopy. Women with IBS should be offered a trial of antispasmodics.
Medical therapy
Should offer appropriate analgesia to control the pain.Women with cyclical pain should be offered a therapeutic trial using hormonal treatment for a period of
3–6 months before having a diagnostic laparoscopy. Women with IBS should be offered a trial of antispasmodics.
Surgical management Lysis of severe adhesions has been shown to benefit patients with chronic pelvic pain. Total abdominal hysterectomy has shown some benefit in some studies. pelvic pain that does not respond to any other therapy may respond to surgery involving cutting or destroying nerves so that pain signal are not transmitted. Surgical management
Lysis of severe adhesions has been shown to benefit patients with chronic pelvic pain. Total abdominal hysterectomy has shown some benefit in some studies. pelvic pain that does not respond to any other therapy may respond to surgery involving cutting or destroying nerves so that pain signal are not transmitted.
Neuro-modulation therapy Uncontrolled studies of sacral nerve stimulation in women with chronic pelvic pain have shown some benefit. Some benefit in using percutaneous tibial nerve stimulation to treat chronic pelvic pain has also been shown. Neuro-modulation therapy
Uncontrolled studies of sacral nerve stimulation in women with chronic pelvic pain have shown some benefit. Some benefit in using percutaneous tibial nerve stimulation to treat chronic pelvic pain has also been shown.

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